Opportunities and challenges for the high-quality development of hernia and abdominal wall surgery in China / 中华外科杂志

Hernia and abdominal wall surgery is a relatively new subspecialty in surgery. Although it started late in China, after 25 years of rapid development, it has made remarkable achievements and has become an important part of surgery, laying a solid foundation for the further development of the discipline. At the same time, one should also be soberly aware of the present deficiencies in this field. The development of the field should be more detailed and in-depth from the following aspects: correct understanding of new concepts of hernia and abdominal wall surgery, establishment of hernia patient registration and quality control system, technological innovation and development of technical equipment, especially the expansion of robot surgical systems, materials science progression to hernia and abdominal wall surgery. Faced with this challenge, China is expected to achieve high-quality development in the field of hernia and abdominal surgery.

Clinical value of mesh prophylaxis for parastomal hernia based on evidence-based medicine / 中华外科杂志

The incidence of parastomal hernia is substantially high, significantly affecting the quality of life of patients with stoma. How to effectively solve the problem of parastomal hernia is a long-term focus of hernia and abdominal wall surgery and colorectal surgery. The European Hernia Society guidelines on prevention and treatment of parastomal hernia published in 2018 has recommended the use of a prophylactic mesh to prevent parastomal hernia for the first time. In the following 5 years, more randomized controlled trials of multi-center, large-sample, double-blind, long-term follow-up have been published, and no significant effect of mesh prophylaxis has been observed on the incidence of parastomal hernia. However, whether mesh could decrease surgical intervention by limiting the symptoms of parastomal hernias would become a potential value of prophylaxis, which requires further research to elucidate.

Re-discussion on the comprehensive treatment strategy of complex ventral hernia from the perspective of intraperitoneal pressure / 中华外科杂志

Complex ventral hernia refers to a large hernia that is complicated by a series of concurrent conditions. Change in intra-abdominal pressure is one of the main pathways through which various factors exert an impact on perioperative risk and postoperative recurrence. Taking abdominal pressure reconstruction as the core, the treatment strategy for complex abdominal hernia can be formulated from three aspects: improving patients' tolerance, expanding abdominal cavity volume, and reducing the volume of abdominal contents. Improving patients' tolerance includes abdominal wall compliance training and progressive preoperative pneumoperitoneum. To expand the volume of the abdominal cavity, implanting hernia repair materials, component separation technique, autologous tissue transplantation, component expend technique, and chemical component separation can be used. Initiative content reduction surgery and temporary abdominal closure may be performed to reduce the volume of abdominal contents. For different cases of complex ventral hernia, personalized treatment measures can be safely and feasibly adopted depending on the condition of the patients and the intra-abdominal pressure situation.

A preliminary report of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis to prevent parastomal hernia / 中华外科杂志

Objective: To examine the preliminary effect of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis for the prevention of parastomal hernia after abdominoperineal resection for rectal cancer. Methods: This study is a prospective case series study. From June 2021 to June 2022, patients with low rectal cancer underwent laparoscopic abdominoperineal resection combined with extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis at the First Department of General Surgery, Shaanxi Provincial People's Hospital were enrolled. The clinical data and postoperative CT images of patients were collected to analyze the incidence of surgical complication and parastomal hernia. Results: Totally 6 cases of patient were enrolled, including 3 males and 3 females, aging 72.5 (19.5) years (M(IQR)) (range: 55 to 79 years). The operation time was 250 (48) minutes (range: 190 to 275 minutes), the stoma operation time was 27.5 (10.7) minutes (range: 21 to 37 minutes), the bleeding volume was 30 (35) ml (range: 15 to 80 ml). All patients were cured and discharged without surgery-related complications. The follow-up time was 136 (105) days (range: 98 to 279 days). After physical examination and abdominal CT follow-up, no parastomal hernia occurred in the 6 patients up to this article. Conclusions: A method of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis is established. Permanent stoma can be completed with this method safely. It may have a preventive effect on the occurrence of parastomal hernia, which is worthy of further study.

Comparative study of laparoscopic Keyhole and Sugarbaker technique in the treatment of terminal paracolostomy hernia / 中华外科杂志

Objective: To compare laparoscopic Keyhole repair with Sugarbaker repair in consecutive patients with parastomal hernia. Methods: From January 2015 to December 2021, 117 patients with parastomal hernia were treated with Keyhole or Sugarbaker laparoscopy repairs in the Department of Hernia and Bariatrci Surgery, the First Affiliated Hospital of University of Science and Technology of China, and the clinical data were retrospectively analyzed. There were 45 males and 72 females, aged (68.6±8.6) years (range: 44 to 84 years). Laparoscopic Sugarbaker repair was performed in 89 cases, and Keyhole repair was performed in 28 cases. The t-test, Mann-Whitney U test, χ2 test and Fisher exact test were used to compare the observation indicators between the two groups, such as operation time, incidence of operation-related complications, and postoperative recurrence rate. Results: The follow-up period was (M(IQR)) 33 (36) months (range: 12 to 84 months). Compared to the Sugarbaker group, the hernia ring area of the Keyhole group was bigger (35 (26) cm2 vs. 25 (16) cm2, Z=1.974, P=0.048), length of stay was longer ((22.0±8.0) d vs. (14.1±6.2) d, t=5.485, P<0.01), and the postoperative rate of recurrence was higher (28.6% (8/28) vs. 6.7% (6/89), χ2=7.675, P=0.006). There was no difference in operation time and postoperative complications between the two groups. Conclusions: Laparoscopic Sugarbaker repair is superior to Keyhole repair in the recurrence rate of parastomal hernia treated with compsite mesh (not funnel-shaped mesh). There are no differences in operation time and postoperative complications between the two groups.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair

INTRODUCTION@#The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population.@*METHODS@#This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups.@*RESULTS@#There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable.@*CONCLUSION@#Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Preoperative botulinum A toxin as an adjunct for abdominal wall reconstruction: a single-center early experience at an Academic Center in New York / Toxina botulínica A pré-operatória como adjuvante na reconstrução da parede abdominal: experiência inicial em Centro Acadêmico em Nova York

ABSTRACT Introduction: the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. Methods: a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. Results: 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). Conclusion: preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.

RESUMO Introdução: a toxina botulínica A (TBA) tem sido usada para alcançar a separação química dos componentes, com resultados favoráveis para o reparo de hérnias ventrais complexas (HVC) com ou sem perda de domínio (PD). O objetivo deste estudo é descrever nossa experiência inicial com a separação química dos componentes nos Estados Unidos. Métodos: estudo retrospectivo observacional com todos os pacientes submetidos a reparo de hérnia ventral complexa com ou sem PD entre julho de 2018 e junho de 2020. A TBA pré-operatória foi injetada em todos os pacientes, guiada por ultrassonografia, bilateralmente entre os músculos laterais para alcançar a denervação química antes da operação. Dados demográficos dos pacientes, local da hérnia, dados peri-operatórios e pós-operatórios são descritos. Resultados: 36 pacientes foram submetidos a esta técnica antes do reparo da hérnia. A idade mediana foi 62 anos (30-87). O tamanho mediano pré-operatório do defeito herniário foi 12cm (6-25) e o defeito mediano intra-operatorio foi 13cm (5-27). O volume mediano do saco herniário pré-operatório foi 1.338mL (128-14.040), o volume mediano da cavidade abdominal pré-operatório foi 8.784 (5.197-18.289) mL e a razão dos volumes foi 14%. A duração mediana da operação para aplicação da TBA foi 45 minutos (28-495). O seroma foi a complicação mais comum no pós-operatório, em oito pacientes (22%). O seguimento pós-operatório mediano foi de 43 dias (0-580). Conclusão: a separação pré-operatória de componentes com TBA é tratamento adjuvante seguro e eficaz em reparos de HVC em que aproximação da fáscia é antecipadamente desafiadora.

Robotic trans-abdominal preperitoneal approach (tapp) approach for lateral incisional hernias / Abordagem robótica transabdominal pré-peritoneal (rtapp) para hérnias incisionais laterais

ABSTRACT Background: Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair. Aim: To describe a robotic assisted surgical technique for incisional lumbar hernia repair. Methods: Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies. Results: Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days. Conclusion: The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

RESUMO Racional: As hérnias incisionais laterais surgem entre a linha alba e os músculos paravertebrais posteriores. Os limites anatômicos contêm várias variações topográficas, como várias estruturas ósseas próximas e escassez de tecido aponeurótico que tornam o reparo particularmente difícil . Objetivo: Descrever uma técnica assistida por robótica para o reparo de hérnia lombar incisional. Métodos: Dados foram coletados retrospectivamente de quatro pacientes que foram submetidos ao reparo de hérnia lombar após nefrectomias abertas por técnica robótica. Os pacientes tinham entre 41-53 anos de idade. Dois possuíam hérnia no flanco direito e os outros dois no flanco esquerdo. Resultados: Os pacientes foram colocados em posição de decúbito lateral contralateral ao lado do defeito. Abordagem pré-peritoneal transabdominal foi realizada em todos os casos. Cada procedimento foi realizado com dois trocárteres robóticos de 8 mm, um periumbilical de 12 mm e um auxiliar de 5 mm, permitindo docking ipsilateral ao lado da hérnia. As hérnias foram identificadas, plano pré-peritoneal foi criado e o saco herniário completamente dissecado, permitindo completa visualização do defeito. Todos os defeitos foram fechados primariamente com fio de sutura 0/1V-Loc. Tela de polipropileno ou ProGripTM foi usada com pelo menos 5 cm de overlap e fixada com sutura transfacial com Vicryl® 0, Evicel® ou combinação dos dois. O espaço pré-peritoneal foi fechado com sutura contínua e os trocárteres removidos. O tempo operatório médio foi de 4 h. O tempo de permanência hospitalar variou entre 0-2 dias. Conclusão: A plataforma robótica é capaz de providenciar vantagens únicas no reparo de hérnias incisionais laterais e representa abordagem minimamente invasiva segura, factível e eficaz para o reparo das hérnias laterais incisionais.

Endoscopic transposition with the hernial sac (eTHS) in ventral hernia repair - technical description / Transposição endoscópica do saco herniário (TeSH) no tratamento da hérnia ventral - descrição da técnica

ABSTRACT Incisional hernia is a late complication of the most frequent after abdominal surgeries, with resulting morbidity that can worsen the condition. The treatment has been done both by open techniques, using screens or not, and by laparoscopic and robotic methods, which use them systematically. However, introducing a permanent foreign body into the tissues requires more surgical time, despite not closing the parietal defect in most cases and a higher risk of infections. New technologies have been trying to improve these results, with absorbable prostheses (biological or synthetic), but their high cost and recurrences remain a severe problem. Even so, standard repair establishes reinforcement with screens, routine, and whether the approach is traditional or mini-invasive. The authors report their first case of endoscopic repair of incisional hernia, which occurred two years ago, with a Brazilian technique already fifty years old: the transposition with the hernia sac proposed by Prof. Alcino Lázaro da Silva in 1971.

RESUMO A hérnia incisional é uma das complicações tardias mais frequentes, após operações abdominais, resultando em alta morbidade. O tratamento tem sido feito tanto por técnicas abertas, com telas ou sem, quanto por métodos laparoscópicos e robóticos, que utilizam próteses de forma sistemática. No entanto, a introdução de um corpo estranho permanente entre os tecidos requer mais tempo cirúrgico, não fecha o defeito parietal na maioria dos casos e está associado a maior risco de infecções. Novas tecnologias têm sido utilizadas para melhorar esses resultados, empregando próteses absorvíveis (biológicas ou sintéticas), mas o alto custo e as recidivas continuam sendo um grave problema. No entanto, a reparação padrão rotineiramente estabelece reforço com telas, seja na abordagem tradicional ou minimamente invasiva. Os autores relatam o primeiro caso do reparo endoscópico de hérnia incisional, usando técnica brasileira com 50 anos de idade: a transposição com o saco herniário, conforme proposta pelo Prof. Alcino Lázaro da Silva, em 1971.

Image Inversion during Xi Robotic ventral hernia repair: making it even more effective / Inversão de imagem em cirurgia robótica de hérnia ventral com a plataforma Da vinci Xi: tornando-a ainda mais ergonômica

ABSTRACT Introduction: currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall. Technical Report: a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes. Conclusion: we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.

RESUMO Introdução: as qualidades da cirurgia robótica em diversos campos da cirurgia minimamente invasiva são notórias e, no cenário de hérnias abdominais, ela tem se mostrado capaz de superar as limitações da laparoscopia facilitando a dissecção, o fechamento do defeito herniário e o posicionamento da tela. O número de abordagens robóticas cresceu exponencialmente e casos ainda mais complexos e inicialmente inadequados tornaram-se recentemente elegíveis para uma cirurgia menos invasiva. A reconstrução adequada da linha alba e livre de tensão ainda é uma grande preocupação na cirurgia de hérnia e, mesmo com a plataforma robótica, dissecar e suturar na parede abdominal anterior pode ser um desafio. Este artigo relata um artifício técnico com inversão de imagem durante a correção de hérnia ventral robótica com a plataforma Da vinci Xi, permitindo ao cirurgião estabelecer uma maneira mais familiar e ergonômica de realizar dissecção e sutura na parede abdominal anterior. Nota Técnica: uma técnica guiada passo a passo com artifício de inversão de imagem é descrita usando comandos e figuras detalhadas para garantir campo cirúrgico ideal e melhor ergonomia ao cirurgião sempre que atuar na correção de hérnias ventrais robóticas com a plataforma Da vinci Xi. Nossa breve experiência de grupo também é relatada, mostrando-se uma técnica fácil e reprodutível entre cirurgiões com resultados seguros. Conclusão: consideramos que o artifício de inversão de imagens é uma característica simples e reprodutível na correção de hérnia ventral robótica. Por meio de um guia passo a passo, este artigo detalha a criação de um artifício técnico que proporciona um campo operatório confortável ao cirurgião atingindo sua melhor proficiência em cirurgia de hérnia.

Training model in abdominal wall endoscopic surgery for ventral hernias. Extended totally extra-peritoneal approach (e-tep)

ABSTRACT Purpose: To develop a reproducible training program model covering the steps of the extended totally extraperitoneal approach (e-tep) technique for correction of ventral or incisional hernia repair. Methods: Training sessions with surgeons in the laboratory using both porcine specimens and a new ethylene vinyl acetate (EVA) model simulating the operative steps of the e-tep technique. Students were interviewed and asked to answer a questionnaire pre and post the sessions to assess their performance and evaluated the course and model. Results: A total of 25 trained abdominal wall surgeons was evaluated at the end of the course. It was obtained a 100% satisfaction score of the training, as well as increased confidence levels up to 9 and 10 in all technical aspects of the surgery, having 96% of the surgeons performed a surgery under supervision of the proctors after the course. Conclusions: This training model is simple, effective, low cost, and replicable in guidance on the beginning of e-tep technique adoption, and performance. As a result, surgeons can get more confident and more able to perform surgeries employing this technique.

Reporte de caso. Uso de toxina botulínica tipo A para la reparación de hernia ventral gigante planeada / Surgical treatment of diabetic foot based on Wagner classification, Case report

Introducción: La incidencia de eventración post quirúrgica es del 2-20%, se da mayormente en pacientes con factores de riesgo durante los primeros tres años posteriores a la cirugía inicial. La mayoría de las hernias de la pared abdominal pueden ser reparadas fácilmente, sin embargo, las hernias gigantes (>10cm de diámetro) o aquellas con pérdida de domicilio requieren métodos de expansión gradual de la pared abdominal pre y/o transoperatoriamente. Se ha descrito que posterior a la aplicación de toxina botulínica serotipo A (TBA) de forma bilateral en la pared abdominal, los defectos disminuyen clínica y tomográficamente hasta 5.25cm, por su efecto selectivo en terminaciones nerviosas periféricas colinérgicas, provocando atrofia muscular sin fibrosis. El efecto máximo ocurre al mes de la aplicación y dura 28 semanas. Esta técnica permite planear preoperatoriamente la magnitud de la cirugía. Nuestro caso, paciente masculino de 33 años. Quien ingresa por politrauma. Se realiza procedimiento quirúrgico abdominal y posteriormente se eviscera en múltiples ocasiones. Se cierra herida y posteriormente desarrolla hernia ventral gigante con la que egresa. Se realiza TC abdominal evidenciando defecto herniario de 15.9cm, con este resultado se aplica toxina botulínica serotipo A en la pared abdominal bilateral (50 unidades en cada lado) guiado por ultrasonido. 25 días después se realiza TC abdominal control que evidencia defecto herniario de 14.7cm y se decide ingreso para cirugía electiva. Se decide llevar a sala de operaciones donde se realiza hernioplastía con liberación de componentes anteriores mas colocación de malla de polietileno (cuatro semanas posteriores a la aplicación de la toxina), quedando defecto totalmente cerrado y sin tensión. Paciente con adecuada evolución posterior a intervención por lo que egresa. Actualmente sin defecto herniario recurrente. Conclusión: El uso de toxina botulínica serotipo A es un nuevo recurso prequirúrgico para la preparación de pacientes con hernias ventrales gigantes, ya que permite el cierre sin tensión en la mayoría de los casos. Además, ayuda a que transoperatoriamente la separación de componentes se realice de una mejor manera, ya que se da mejor manipulación al momento de desplazar las estructuras musculares. Idealmente se debe de realizar la intervención quirúrgica cuatro semanas posteriores a su aplicación. (AU)

ntroduction: The incidence of post-surgical eventration is 2-20%, it occurs mostly in patients with risk factors during the first three years after the initial surgery. Most abdominal wall hernias can be easily repaired, however, giant hernias (>10cm of diameter) or those with the loss of domain require methods of gradual expansion of the abdominal wall pre or intraoperatively. It has been described that after the application of botulinum toxin A bilaterally in the abdominal wall, the defect can decrease clinically and tomographically up to 5.25cm, due to its selective effect on cholinergic peripheral nerve endings, that cause muscle atrophy without fibrosis. The maximum effect occurs one month after the application and lasts 28 weeks. This technique allows to plan preoperatively the magnitude of the surgery. Description of case: A 33 year old male patient, who entered the emergency room due to polytrauma. Abdominal surgical procedure was performed and later he eviscerates on multiple occasions. The wound was closed and later he develops a giant ventral hernia with which it is discharged. An abdominal CT was performed, showing a hernia defect of 15.9cm. With this result botulinum toxin A was applied guided by ultrasound bilaterally in the abdominal wall (50 U on each side). A control abdominal CT was performed after 25 days, which it revealed a hernia defect of 14.7 cms, so admission was decided for elective surgery. The patient was taken to the operating room where a hernioplasty with anterior components separation plus the placement of a polyethylene mesh was performed (four weeks after the application of the botulinum toxin A), the hernia defect was completely close without tension. The patient had an adequate post-surgical evolution for which it was discharge. Currently without a recurrent hernia defect. Conclusion: The use of botulinum toxin A is a new pre-surgical resource for the preparation of patients with giant ventral hernias, since it allows the closure without tension in most cases. In addition, it helps transoperatively with the components separation, since there is a better manipulation at the time of displacing the muscular structures. Ideally, the surgical intervention should be performed four weeks after its application. (AU)

Incisional hernioplasty techniques: analysis after open bariatric surgery / Análise das técnicas de hernioplastia incisional após cirurgia bariátrica aberta

ABSTRACT Background: The best technique for incisional hernioplasty has not been established yet. One of the difficulties to compare these techniques is heterogeneity in the profile of the patients evaluated. Aim: To analyze the results of three techniques for incisional hernioplasty after open bariatric surgery. Method: Patients who underwent incisional hernioplasty were divided into three groups: onlay technique, simple suture and retromuscular technique. Results and quality of life after repair using Carolina's Comfort Scale were evaluated through analysis of medical records, telephone contact and elective appointments. Results: 363 surgical reports were analyzed and 263 were included: onlay technique (n=89), simple suture (n=100), retromuscular technique (n=74). The epidemiological profile of patients was similar between groups. The onlay technique showed higher seroma rates (28.89%) and used a surgical drain more frequently (55.56%). The simple suture technique required longer hospital stay (2.86 days). The quality of life score was worse for the retromuscular technique (8.43) in relation to the onlay technique (4.7) and the simple suture (2.34), especially because of complaints of chronic pain. There was no difference in short-term recurrence. Conclusion: The retromuscular technique showed a worse quality of life than the other techniques in a homogeneous group of patients. The three groups showed no difference in terms of short-term hernia recurrence.

RESUMO Racional: A melhor técnica de hernioplastia incisional ainda não foi definida. Uma das dificuldades na comparação é a heterogenicidade no perfil dos pacientes avaliados. Objetivo: Analisar os resultados de três técnicas de hernioplastia incisional após cirurgia bariátrica aberta. Método: Os pacientes que realizaram hernioplastias incisionais foram estudados e divididos em três grupos: técnica onlay, sutura simples e técnica retromuscular. Resultados e qualidade de vida após o reparo utilizando o Carolina's Comfort Scale foram avaliados através de análise de prontuários, contato telefônico e consultas eletivas. Resultados: Foram analisados 363 relatos cirúrgicos e 263 foram incluídos: técnica onlay (n=89), sutura simples (n=100), técnica retromuscular (n=74). O perfil epidemiológico dos pacientes foi similar entre os grupos. A técnica onlay apresentou maiores taxas de seroma (28,89%) e usou dreno com maior frequência (55,56%). A sutura simples obteve maior tempo de internação (2,86 dias). O escore de qualidade de vida foi pior na técnica retromuscular (8,43) em relação à onlay (4,7) e à sutura simples (2,34), especialmente devido às queixas de dor crônica. Não houve diferença quanto a recidiva em curto prazo. Conclusão: A técnica retromuscular apresentou pior qualidade de vida do que as demais técnicas em um grupo homogêneo de pacientes. Os três grupos não mostraram diferenças em termos de recidiva de hérnia em curto prazo.

Biomechanical and adhesion comparison of linea alba prophylactic reinforcement with coated and uncoated three-dimensional T-shaped mesh in rabbits

Abstract Purpose: Incisional hernia (IH) is a frequent complication of median laparotomy. The use of prophylactic mesh to reduce IH incidence has gained increasing attention. We hypothesized that in an animal model, linea alba prophylactic reinforcement with a three-dimensional T-shaped polypropylene mesh results in greater abdominal wall resistance. Methods: Study was performed in 27 rabbits. After abdominal midline incision, animals were divided into three groups according to the laparotomy closure method used: (1)3D T-shaped coated mesh; (2)3D T-shaped uncoated mesh; and (3) closure without mesh. After 4 months, each animal's abdominal wall was resected and tensiometric tests were applied. Results included IH occurrence, adhesions to the mesh, and wound complications. Results: There was no significant difference between the groups in maximum tensile strength (p=0.250) or abdominal wall elongation under maximum stress (p=0.839). One rabbit from the control group developed IH (p=1.00). Small intestine and colon adhesions occurred only in the uncoated mesh group (p<0.001) and the degree of adhesions was higher in this group compared to the coated mesh group (p<0.05). Conclusion: Use of the current 3D T-shaped prophylactic mesh model did not result in a significant difference in tensiometric measurements when compared with simple abdominal wall closure in rabbits.

Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias / Hérnias ventrais por acesso lateral totalmente extraperitoneal robótico (eTEP): dez etapas essenciais na padronização técnica

ABSTRACT Objectives: described by Dr. Jorge Daes, principles of the enhanced view totally extraperitoneal (eTEP) has been widely used in the armamentarium of ventral hernia repair recently. Robotic assisted eTEP technique feasibility has been proved, however, a complete understanding of retromuscular abdominal wall planes and its landmarks still uncertain in a majority of general surgeons. The aim of this report is to propose a technical standardization and its anatomic concepts in the robotic-assisted eTEP ventral hernia repair. Methods: our group describes 10 key steps in a structured step-by-step approach for a safe and reproducible repair based on well defined anatomic landmarks, identification of zones of dissection and correct restoration of the linea alba. Results: the standardization has been developed 2 years ago and applied to all patients. A robotic-assisted surgery with 3 robotic arms is performed in a lateral docking setup. Feasibility is established and reproducibility is high among general surgeons. Conclusion: we present a standardized side docking robotic assisted eTEP approach for ventral hernia repairs with 10 key steps. We believe understanding the landmarks and a step-by-step guidance based on the concepts of retromuscular abdominal wall anatomy foment a safe learning of minimally invasive restoration of the abdominal wall integrity regarding non-expert surgeons.

RESUMO Objetivo: descritos pelo Dr. Jorge Daes, os princípios da visão aprimorada totalmente extraperitoneal (eTEP) têm mais recentemente sido utilizados no arsenal de reparos de hérnias ventrais. A realização da técnica de reparo totalmente extraperitoneal com o uso da robótica mostrou-se viável. No entanto, o verdadeiro conhecimento dos planos da parede abdominal retromuscular e os referenciais ainda são incertos para a maioria dos cirurgiões gerais. O objetivo deste artigo é propor padronização técnica e conceitos anatômicos no reparo de hérnia ventral robótico totalmente extraperitoneal (eTEP VHR). Métodos: nosso artigo descreve 10 etapas essenciais em abordagem estruturada passo a passo para procedimento seguro e reprodutível com base em referenciais anatômicos bem definidos, identificação de zonas de dissecção e restauração correta e completa da linha alba. Resultados: a padronização foi desenvolvida há 2 anos e aplicada a todos os pacientes. A cirurgia robótica é realizada com três braços da plataforma e por docking lateral. Conforme descrita, a reprodutibilidade e segurança são altas entre os cirurgiões gerais. Conclusão: apresentamos abordagem padronizada da técnica robótica de reparo de hérnia ventral totalmente extraperitoneal (eTEP VHR) em docking lateral por meio de 10 etapas essenciais. Acreditamos que a compreensão dos referenciais anatômicos e orientação passo a passo com base nos conceitos da anatomia do espaço retromuscular fomentam o aprendizado seguro, na atuação de cirurgiões não experientes durante a restauração minimamente invasiva da integridade da parede abdominal.

Maximum inspiratory and expiratory pressures in the pre and postoperative periods of patients with incisional abdominal hernia corrected by Lázaro da Silva technique / Pressões máximas inspiratórias e expiratórias no pré e pós-operatório de pacientes com hérnias incisionais abdominais corrigidas pela técnica de Lázaro da Silva

ABSTRACT Objective: To verify the effect of longitudinal abdominal incisional herniorrhaphy on respiratory muscle pressure. Method: The technique of incisional herniorrhaphy used was proposed by Lázaro da Silva. To measure the pressure, we used a water manometer in 20 patients, median age 48.5 years (range 24 70). We analyzed the maximum inspiratory pressure at the level of residual volume (IP-RV) and functional residual capacity (IP-FRC) and the maximum expiratory pressure of functional residual capacity (EP-FRC) and total lung capacity (EP-TLC) in the preoperative and late postoperative (40 90 days) periods, in 13 patients with large incisional hernias and in 7 patients with medium incisional hernias. Results: There was a significant increase in IP-FRC (p = 0.027), IP-RV (p = 0.011) and EP-TLC (p = 0.003) in patients with large incisional hernias. EP-FRC increased, but not significantly. In patients with medium incisional hernias, the changes were not significant. Conclusion: Surgical correction of large incisional hernias improves the function of the breathing muscles; however, surgery for medium incisional hernias does not alter this function.

RESUMO Objetivo: verificar o efeito da herniorrafia incisional abdominal longitudinal na pressão dos músculos da respiração. Método: a técnica de herniorrafia incisional utilizada foi a proposta por Lázaro da Silva. Para aferir a pressão foi utilizado manômetro de água, em 20 pacientes, idade mediana 48,5 anos (mínimo 24, máximo 70). Foram analisadas a pressão máxima inspiratória no nível do volume residual (PIVR) e da capacidade residual funcional (PICRF) e a pressão máxima expiratória da capacidade residual funcional (PECRF) e da capacidade pulmonar total (PECPT), no pré-operatório e pós-operatório tardio (entre 40 e 90 dias), em 13 pacientes com hérnias incisionais grandes e em 7 pacientes com hérnias incisionais médias. Resultados: houve aumento significante da PICRF (p=0.027), da PIVR (p=0.011), da PECPT (p=0.003) nos pacientes com hérnias incisionais grandes. A PECRF aumentou, porém de forma não significante. Nos pacientes com hérnias incisionais médias as alterações não foram significantes. Conclusão: a correção cirúrgica da hérnia incisional grande melhora a função dos músculos da respiração, porém a cirurgia da hérnia incisional média não altera a referida função.

Evaluation of polyamide surgical mesh as an abdominal ventral implant in rabbits

Abstract Purpose: To evaluate abdominal ventral wound healing by using a specific biomaterial, a handmade polyamide surgical mesh. Methods: A surgical incisional defect was made in ten rabbits to simulate a hernia in the ventral abdominal musculature. A polyamide surgical mesh was used in hernioplasty. They were monitored for surgical wound healing, and macroscopically and histologically evaluated at the end of the experiment. The polyamide surgical mesh did not cause foreign body reaction, pain, edema, or infection in the surgical site. The manure production was not affected by intestinal tissue adherences to the mesh, consistent with the ultrasonography result where adherences were not observed and organized scarring tissue formed in the incisional defect. The polyamide mesh was fixed over the abdominal wall, and its external and internal sides were surrounded by a vascularized connective tissue. Results: None of the experimental animals developed adherences from internal organs to the polyamide mesh, except two rabbits where the omentum formed adherence to the internal scarring tissue without present herniation or compromise of the rabbit's health. Conclusion: Polyamide surgical mesh for hernioplasty presents, in rabbits, excellent biocompatibility, with minimal body adverse reactions and low cost.